Claims workbench/CLM-2026-025033
Institutional claim · UB-04 · EDI 837I

CLM-2026-025033

Summit Regional Medical Center, Emergency Medicine. Service 2026-07-26 at emergency room (POS 23). Received 2026-08-27.

Pended
Billed
$2,179.00
2 lines
Allowed
$1,198.45
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
CO16, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Summit Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
1269847210
Network
In network
Rendering NPI
1269847210
Location
Mesa, AZ · TIN 62-8021640
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199285
rev 0450
Emergency department visit, high severity with threat to life—11$1,970.00$1,083.50——PendedCO16
271046
rev 0320
Chest X-ray, two views—12$209.00$114.95——PendedCO16
Totals$2,179.00$1,198.45——
Diagnoses (ICD-10-CM)
  • 1. J18.9 Pneumonia, unspecified organismprincipal
  • 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
Claim header
Patient account
PA-822172
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailCO16Claim record is not attached to a resolved identity.
Claim lacks information needed for adjudication
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Regional Medical Center (1269847210).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Summit Regional Medical Center2026-07-26 09:00

    Patient seen for pneumonia, unspecified organism.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-822172.pdf9 pages

    Itemised statement totalling $2179.00 across 2 lines.

  • Er reported_report_PA-822172.pdf3 pages

    Emergency department record: triage acuity 4, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Claim record is not attached to a resolved identity. Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue